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MAW Youth Medical Form

2014 CPYC Regatta to Benefit Make-A-Wish
August 1st, 2015
Medical Form
Skipper’s Name:___________________________________ DOB:_______________________
Mother’s Name:____________________________________ Phone:______________________
Father’s Name:_____________________________________ Phone:______________________
Alternative Emergency Contact:________________________Phone:_____________________
Physician:_________________________________________ Phone:_____________________
Allergies/Health Problems:_______________________________________________________
Health Insurance Carrier:____________________________ Insurance #:__________________
I understand that a responsible attempt will be made to contact me should an emergency arise, but in the event that the
Winchester Boat Club is unable to reach any of the names above, I give my permission to transport my child to the nearest source
of emergency care, in order that necessary medical treatment not be delayed.
Parent or Guardian (print):________________________________________________________
Parent or Guardian (signature): ___________________________________Date:_____________
Crew’s Name:___________________________________________ DOB:_________________
Mother’s Name:_________________________________________Phone:__________________
Father’s Name:__________________________________________Phone:__________________
Alternative Emergency Contact:____________________________ Phone:_________________
Physician:______________________________________________Phone:__________________
Allergies/ Health Problems:_______________________________________________________
Health Insurance Carrier: ____________________________ Insurance #:__________________
I understand that a responsible attempt will be made to contact me should an emergency arise, but in the event that the
Winchester Boat Club is unable to reach any of the names above, I give my permission to transport my child to the nearest source
of emergency care, in order that necessary medical treatment not be delayed.
Parent or Guardian (print):________________________________________________________
Parent or Guardian (signature): ___________________________________Date:_____________